STROKE BY THE NUMBERS South Carolina Stroke RACE South Carolina Stroke RACE Rapid Arterial oCclusion Evaluation created by SCD DHEC Bureau of EMS History

Historical Context  EMS is the first medical contact in over 50% of all stroke victims in U.S.  Unless the patient had altered LOC, strokes were treated as non-emergent events and transported routine to ER  Prehospital care seen only as supportive and permanent disability was seen as inevitable, much like cardiac arrest in the 70’s  Typically Cincinnati Stroke Scale used to confirm stoke event  MEND and NIHSS taught in school but rarely used in field EMS & Strokes System

Stroke Care in South Carolina South Carolina now has the third best “door to balloon” time for STEMI care in the United States. 1 No reason why stroke care should not follow suit Currently there are 21 designated stroke centers in South Carolina: HFAP – 1, DNV – 2 TJC – 18 8 hours Most EMS services have adopted State Stroke Protocol: “The Reperfusion Checklist should be completed for any suspected stroke patient. With a duration of symptoms of less than 8 hours, scene times should be limited to 10 minutes, early destination notification / activation should be provided and transport times should be minimized based on the EMS System Stroke Plan.” (1) SCHA, 2013 How we work

How we have to do business at BEMS POLICIES / PROCEDURES - EMT manuals, protocols, formulary REGULATION 61-7, 61-96, STATUTE series – Articles – 1, 3, 5, 6, etc

What the Law says…. (5) It is also in the best interest of the people of South Carolina to modify the state's emergency medical response system to ensure that potential stroke patients are quickly identified and transported to and treated in facilities that have the capability for providing timely and effective treatment for stroke patients. (B) The department, in consultation with the Stroke System of Care Advisory Council, shall adopt and distribute a nationally recognized, standardized stroke-triage assessment tool. The department must post the stroke-triage assessment tool on its website and provide a copy, which may be an electronic copy, of the stroke-triage assessment tool to each licensed emergency medical services provider before January 31, Each licensed emergency medical services provider must establish a stroke assessment and triage system that incorporates the department approved stroke-triage assessment tool. Your text here time

Time Context  Greatest portion of delay between onset of symptoms and emergency care is the time it takes for a patient to recognize the signs of stroke and decide to seek medical attention.  Between 50-75% of ischemic stroke patients do not arrive at hospital within 3-hours.  Value of early identifying an LVO in the field and pre-notifying the stroke center EMS & Strokes Criteria

What criteria do we use / need? Following the model and success of STEMI care in the field, (TIME =Cardiac muscle) prehospital pre-notification is essential to advance stroke care since (TIME = Brain) There are many developed stroke scale models available for field use. Most used by EMS only capture sensitivity for + or – to rule in/out a stroke Early detection of LVO (or ELVO) is as essential to stroke care as ST elevation to STEMIs Qualitative Score (+/-) vs. Quantitative Score (# value) NIHSS is the “gold standard” by which all stroke scales are based. Need for a quantitative SS that has been validated with EMS data and is correlated to the NIHSS (“gold standard”) that can detect an LVO. 12

“We need a 12 Lead for your head”

For the Record…

Stroke by the Numbers Stroke Scale Items NIHSSCPSSFASTFAST -EDzNIHSSsNIHSS5sNIHSS8MENDSLAPSSLAMSMENSAVPURACE LOCXXXXX LOC Questions XXX LOC Commands XXXXXX GazeXXXXXXXX Visual Fields XXXXXX Facial Palsy XXXXXXX Motor Arm Drift Left XXXXXXXX Motor Arm Drift Right XXXXXXXX Motor Leg Drift Left XXXXXX Motor Leg Drift Right XXXXXX Limb Ataxia XX SensoryXX LanguageXXXXXXX DysarthriaXXXXXXX ExtinctionXXX GripX

Stroke by the Numbers Stroke Scale Items NIHSSCPSSFASTFAST -EDzNIHSSsNIHSS5sNIHSS8MENDSLAPSSLAMSMENSAVPURACE LOCXXXXX LOC Questions XXX LOC Commands XXXXXX GazeXXXXXXXX Visual Fields XXXXXX Facial Palsy XXXXXXX Motor Arm Drift Left XXXXXXXX Motor Arm Drift Right XXXXXXXX Motor Leg Drift Left XXXXXX Motor Leg Drift Right XXXXXX Limb Ataxia XX SensoryXX LanguageXXXXXXX DysarthriaXXXXXXX ExtinctionXXX GripX

Stroke by the Numbers Stroke Scale Items NIHSSFASTEDzNIHSSsNIHSS5sNIHSS8LAMSMENSRACE LOCXXX LOC Questions X LOC Commands XXX GazeXXXXXXX Visual Fields XXXXX Facial Palsy XXXX Motor Arm Drift Left XXXX Motor Arm Drift Right XXXX Motor Leg Drift Left XXXXX Motor Leg Drift Right XXXXX Limb Ataxia X SensoryX LanguageXXXXXXX DysarthriaXXXX ExtinctionXX GripX All NIHSS-based scales validated from ED admission or ED presentation; not prehospital collected. RACE validated by EMS data. Perez, et al; 2014

RACE: Stroke by the Numbers RACE The Rapid Arterial oCclusion Evaluation (RACE) scale was designed based on the National Institutes of Health Stroke Scale (NIHSS) – the validated neuroscience “gold standard” It is a Quantitative Scale vs. Qualitative Scale  More Objective (number value) vs. Less Subjective (+ or -) Cincinnati Stroke Scale, LAPSS, and MENDS are all Qualitative A scale based on the NIHSS that is more user-friendly for prehospital field usage RACE RACE would allow the State to capture quantifiable data for research

RACE: Stroke by the Numbers The Tirschwell et al study (Stroke. 2002;33: ) noted that sNIHSS-8 and sNIHSS-5 (shortened versions of the full NIHSS or NIHSS-15) retained the predictive ability (90-day outcomes) of the original NIHSS and could be of value for prehospital use. The Zandieh et al study (Clinical Neurology & Neurosurgery. 2012;10:034) developed an even shorter, parsimonious NIHSS-based tool with prehospital implications that was equally predictive (28-day mortality) as the original NIHSS. RACE Pérez de la Ossa et al study ( Stroke. 2014;45: ) validated RACE and recommended it for prehospital care usage. RACE Technically, the RACE is a mNIHSS-6.

RACE 1. Facial Palsy  None present= 0  Mild = 1  Moderate to Severe = 2 2. Arm Motor Function  Normal to Mild= 0  Moderate = 1  Severe = 2 3. Leg Motor Function  Normal to Mild= 0  Moderate = 1  Severe = 2 ____ SUBSCORE ____

RACE 4. Head Gaze Deviation  Absent = 0  Present = 1 5. Aphasia * (if right side hemiparesis)  Performs both tasks correctly= 0  Performs 1 task correctly = 1  Performs neither tasks = 2 6. Agnosia † (if left side hemiparesis)  Patient recognizes his/her arm and the impairment = 0  Does not recognized his/her arm or the impairment = 1  Does not recognized his/her arm nor the impairment = 2 ____ SUBSCORE ____ * † see next slide for explanation

RACE RACE RACE is a 5 or 6 item scale based on the side of weakness right * Aphasia (if right side hemiparesis) : Ask the patient and evaluate if the patient obeys. 1. “Close your eyes” 2. “Make a fist” left † Agnosia (if left side hemiparesis): Ask the patient: 1. while showing him/her the paretic arm: “Whose arm is this” and evaluate if the patient recognizes his own arm. 2. “Can you lift both arms and clap” and evaluate if the patient recognizes his functional impairment.

RACE: Stroke by the Numbers Test Item Test ItemRACE NIHSS Equivalent Facial Palsy Arm Motor Function Leg Motor Function Head Gaze Deviation Aphasia (R side)0-2 Agnosia (L side)0-2

RACE: Stroke by the Numbers The cut-score value of RACE for recommendation to divert to a CSC is ≥4 The global accuracy of the RACE for large vessel occlusion (LVO) is (c-statistic, 0.84; 95% Confidence Interval (CI), ρ = 0.79–0.89). RACE is comparable with NIHSS to predict LVO (c- statistic, 0.85; 95% CI, ρ = 0.81–0.89). RACE has a high sensitivity (89%) and specificity (55%) with a cutoff point of 4 for LVO. A sensitivity (85%) and specificity (65%) with a cutoff of 5 for LVO. Last

RACE: Stroke by the Numbers Questions?

Stay in Tune with EMS ! SCEMSPORTAL. HAVE A GOOD IN CIS !!!!